An ongoing dialogue on HIV/AIDS, infectious diseases,
January 3rd, 2025
On the Inpatient ID Consult Service, Oral Antibiotics Have a Rocky Road to Acceptance
Home IV antibiotics are not fun — just look at her face. (Image: Pixabay)
Having just completed a stint doing inpatient ID consults, I came away impressed with three things:
- Staph aureus remains the Ruler of Evil Invasive Pathogens in the hospital setting.
- You can “jinx” a holiday season by saying it’s usually quiet on Christmas. This year it sure wasn’t quiet, hoo boy.
- Some surgeons aren’t ready to accept the evidence about oral antibiotics being just as good as intravenous (IV) for their patients with severe infections.
Note I wrote some surgeons — not all. But with apologies to authors of the POET and OVIVA studies, and in particular to Dr. Brad “Oral is the New IV” Spellberg, who has been a leader in this space, I bring you now a blended version of several conversations I had with surgical colleagues when I recommended oral antibiotics for their patients:
Me: I heard from your resident that you wanted a PICC line for Mr. Smith. Did you see our consult note?
Surgeon: Thanks for following him. No, didn’t read it — what did it say?
Me, not at all surprised that the attending surgeon didn’t read our Masterpiece: We recommended that he go home on trim sulfa, one double-strength tablet twice daily. (I might have said Bactrim. Ok, I did.) The organism is susceptible, and it has excellent oral absorption. That way we can spare him the PICC line and all the risks and hassles of home IV therapy.
Surgeon: This was a very severe infection — I’d prefer we be as aggressive as possible in treating it.
Me: Understood. But there’s literature now showing that oral antibiotics are comparable to and safer than IV. I’m especially comfortable in recommending it when there is a high GI-absorption option like Bactrim, a susceptible bug, and there has been source control, as in this case.
Surgeon: Thanks for sharing that — I’m not up on the ID literature, but this infection threatened to get into the joint (or bloodstream or CNS — it’s a generic conversation). In the OR, we drained frank pus*, and had to copiously** irrigate the site with 3 liters of sterile saline.
(*I always felt bad for people named “Frank” when I hear this expression.)
(**Surgeons frequently use the word “copiously” when they irrigate infections. And how do they decide on the number of liters to use?)
Me: Yes, I understand it was bad. But it sounds like you got it all — that’s probably the most important thing. Another thing, he’s taken Bactrim before, and we know he tolerates it well.
Surgeon: Maybe use orals for a milder infection, but not for an infection this severe. I told him after the surgery he’d be going home on IVs. If we use oral antibiotics and it fails, I’d feel bad we didn’t attack this as hard as possible with IV antibiotics.
Me: Ok, we’ll set up the home antibiotics.
Surgeon: Great, thanks so much. Really appreciate your help.
Me: No problem. He’ll go home on 6 weeks of IV colistin.
(That’s an ID joke, ha ha. It really was ceftriaxone.)
A few comments about this exchange.
- It’s entirely friendly. We both want what’s best for the patient.
- The surgeon has already made up his mind before consulting us that IV is preferred over oral antibiotics.
- There is deep anxiety about oral antibiotics not being “aggressive” enough with a “severe” infection, with the concern about an error of omission rather than commission. Meaning, a bad outcome by doing less outweighs concerns about a bad outcome by doing more, which is why I bolded this sentence, and repeat it here: “If we use oral antibiotics and it fails, I’d feel bad we didn’t attack this as hard as possible with IV antibiotics.”
This last point gets to the core of this debate. Surgeons, who by their very nature are quite active in their day-to-day practice, may not comfortable with what they consider a less invasive approach. Intravenous antibiotics are more challenging, more intensive, typically reserved for inpatients or critically ill people, hence (they think) they must be better.
This is a particularly tough nut to crack. And I get it — if an infection is severe, don’t we want to treat it as aggressively as possible?
The problem with this line of thinking is that it ignores good clinical evidence (including randomized trials and well-done observational studies); it does not factor in the risks, hassles, and cost of IV therapy; and it forgets the important principle Brad often cites, which is that the bacteria don’t care how the antibiotic got there — just that it got there.
In some ways, we’ve fostered the surgeon’s view by taking on the management of home IV therapy — often called Outpatient Parenteral Antimicrobial Therapy, or OPAT — as a core responsibility of us specialists in Infectious Diseases. After all, who knows antibiotics better than we do?
But this has insulated them from the problems. If we had each surgeon manage OPAT for their patients, it would open their eyes about misplaced monitoring labs, clotted and infected lines, upper extremity DVTs, failed home deliveries of medications, confused care providers at home, capricious vancomycin levels, and miscellaneous other mess-ups that are an unwelcome part of home IV therapy.
I have a hunch that if Dr. Orthopod P. Neurosurgeon had to manage these and myriad other OPAT issues, they’d be quite willing to consider an oral option if we told them a good one existed.
16 Responses to “On the Inpatient ID Consult Service, Oral Antibiotics Have a Rocky Road to Acceptance”
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Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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So to please the surgeon you added enormous cost to the patient (you are spending their money after all) and increased risk with zero added benefit. That is ethical how? When my surgeons wanted to do iv instead of po I said fine, you take care of it, I will not do what I think is wrong/unnecessary. And then they always went with my recs. I was always the patients doctor, not the surgeons. If you phrase it as the patient as the priority, it is a very easy nut to crack.
Hi Mark,
Thanks for your comment, and suggestions. This is a generic case, so rest assured that no one was harmed with either cost or risk! But in “real life”, there is often no 100% correct answer, and I’d argue that in settings where there is more than one right way to go about a treatment, it’s ok to make the decisions as part of a team approach to care — and that team includes the consulter, the patient, and their preferences.
-Paul
Mark Crislip and Paul Sax disagreeing is like watching Mom and Dad fight.
100% true and LMAO
Speaking as a nephrologist, I believe that so much of delivering good care on a consult service is getting along well with our colleagues. The most important thing to do when disagreeing is to have a discussion with the person who consulted you, which is what happened in this made-up case.
Reminds of a call I got from a surgeon upset because he wanted me recommend vancomycin for an MSSA infection because it was “stronger.”
What surprises me most is that the surgeon did not defer to your recommendation even after you pointed to the evidence for and greater safety of oral therapy. I wonder if he had already told the patient about his plan and rationale (“attack this as hard as possible with IV therapy”) and would have felt embarrassed to modify the plan.
Sigh…
Though this case is a blend of many, indeed you are correct that the patient is often already told they will receive IV antibiotics as the best approach to their serious infection before the ID consultant is called in. As you note, this makes it hard to change course.
– Paul
It’s mind-boggling that the surgeon consults the ID expert and then steamrolls over the expert’s *expert* opinion. What would the surgeon think if the ID doc told them their surgical approach was wrong and the ID doc knew better?
Great piece, Paul.
Couple of things stick out in the post and some of the comments.
1. How did we get to a place where we, as antibiotic experts, put recommendations in the chart about antibiotic treatment only to have them disregarded? Brad also speaks on this and has some salient points about advocacy for the speciality and the role of our professional organizations.
2. The burden of proof is always placed on the “new” practice (“new” to the person who isn’t familiar with the data anyway) BUT the goal posts seem to keep moving in an effort to justify our own anxieties. And this is the challenge. When/how do we stop the goal posts from moving? There seems to be a point in which we have to put our foot down but that is hard to do when many ID specialists still don’t commonly (sometimes ever) recommend oral. Nothing will be right in every case (organism, extremes of weight, intolerance, resistance, etc), however even despite that I think uptake of orals amongst ID clinicians has been varied. I’ve started to ask clinicians what evidence points to the fact that IV would be more effective than oral (if I encounter resistance to the idea of oral when that’s what I recommended).
3. Your point about the patient being told that IV is the only treatment by non-ID specialists is what I really have a problem with. I have encountered situations in which oral was not even presented as an option and the patient (who is depending on us to present the information/options that are available because they are not ) would have incurred significant financial harm in addition to receiving low value and insensitive care.
Thanks for highlighting this important issue!
—Zack
Point 1 is very poignant! It would be highly insulting & unprofessional for an ID specialist to, essentially, force a surgeon into performing a procedure they didn’t consider neccesary.
Interesting piece and apologies for the ignorance of my UK perspective. Tricky to counter the ‘IVs are stronger’ dogma.
Why go along and arrange OPAT if you thought oral antibiotics were best for the patient?
And if providing OPAT care why not switch them to oral after a few days or so when they’re ‘your’ patient? This saves face a bit for both sides but no doubt perpetuates the myth IVs are better to surgeons and patients.
Is there a financial incentive to keep on IVs and manage in OPAT?
Thanks,
Jon
Good questions, Jon. Certainly no financial motivation for the surgeons. They are motivated by a strong desire to “do everything”, which translates into similar requests for the broadest spectrum antibiotics when a narrower choice would do, and to give longer courses of preventive antibiotics when just a prophylactic pre-op dose is safer and does just fine.
-Paul
Interesting. I have had the opposite experience – working in a limited resources setting in which most of the time we do not have access to OPAT, surgeons will often ask me “good, but is there any oral antibiotics so we can send our patient home?”.
I agree with Doctor Sax’s opinion in that maybe OPAT is too “easy” for surgeons – it’s freely available (from their point of view) and they don’t have to worry about its complications.
It took a long time for even many ID providers to get comfortable with the idea of oral antibiotics rather than IV antibiotics, for some still a work in progress… It is time for ID to have more presence/collaboration with surgical colleagues ie. antibiotics tailored education for surgery residents, mandatory resident rotation with ID given the state of MDRO we are in, sharing ID related evidence based medicine in their conferences, publishing this sort of experience in their journals to be seen…
Great discussion. This topic speaks to me because we recently established a COPAT program at our institution. A few comments:
1. I find it comical that the ID expert opinion can be overridden by folks who are the least qualified to make recommendations about antimicrobial therapies. These non-expert recommendations are often based on over-simplified and gross misunderstandings of antimicrobial therapeutics, or irrational thinking. Funny how nobody can override other specialists when they deem a certain intervention not useful. For example, you can’t argue with a surgeon who says the patient is not a surgical candidate, or you can’t prescribe chemotherapy when the oncologist says no, or you can’t perform endoscopy on a patient when the gastroenterologist claims the procedure is not necessary. For some strange reason, it is acceptable and maybe even normalized among some folks that an ID recommendation on antibiotic choice and duration can be overruled. Sometimes even before the ID opinion is sought, it is already invalidated when another doctor tells the patient that they need to be on IV antibiotic for several weeks, not even allowing the ID physician to have a proper and informed discussion about the treatment options. To an outsider, a recommendation on drug therapeutics might look easy on the surface level, but what they don’t see is the complex thought process and critical thinking that takes place to arrive at that decision. The approach taken to make a decision is sometimes more important than the decision itself.
2. It is important that ID docs reclaim, claim and maintain authority over their expertise and not allow non-ID docs to exert superiority over their discipline. The fact that ID physicians do not own or control any unique resources make them vulnerable to having their expertise questioned and disregarded. Other docs can order and prescribe the same tests and drugs that I can. If there’s no ID doc to run an OPAT program, a generalist can easily replace them. They might not do as good of a job as an ID expert, but they will get the job done nonetheless. If there’s no anesthesiologist, then surgery cannot move forward. If there’s no ID doc, no problem, just get someone else to order the antibiotic or test. Some specialists appear to have intrinsic value and a hospital system is incomplete without them. Every day, I feel the need to prove my worth to the system. I am not just an antibiotic doctor or a gatekeeper to OPAT. If all I do is cater to people’s requests for restricted drugs or home IV, then what is the point of my existence? By giving in to demands that I do not agree with, I am discrediting, devaluing and invalidating myself as a specialist, and giving a bad name to my discipline. I take pride in the fact that sometimes my opinion or recommendation surprises people or make them feel uncomfortable – that means I’m adding value to patient care because I am able to apply the best evidence and make rational decisions when others are afraid or reluctant to do so. Using oral antibiotic over IV is just one example.
3. Agree that it is important to establish and maintain a good relationship with the referring physician. This requires mutual respect for each other’s skills and expertise. I will always defer to other specialists when the issue at hand is outside my scope of practice. However, it is not uncommon for others to make recommendations or opine on a complex infectious diseases topic when they lack the expertise to do so. As a patient, who do you listen to? Maybe ID docs need to gently remind others that bugs and drugs is their area of expertise, and that an ID opinion should not be treated as equal to a non-ID opinion regarding complicated infections. It is absurd that a debate between ID and non-ID on an infection issue even takes place. It is just as asinine as a debate between ID and a cardiologist about the best drugs to treat heart failure – there is simply no debate. I can still be respectful to the referring physician while exercising my authority over a topic that I can rightfully claim as part of my expertise. Just remind yourself that you are treating the patient, not other doctors’ discomfort, fear or anxiety about the infection.
4. Despite ample evidence to support a particular intervention (ie. PO over IV, or short duration over long duration), there continues to be wide practice variations among ID docs for various reasons (ie. not comfortable with change, not convinced by evidence, evidence is weak or lacking, loss of financial/personal gains, etc.). This makes it difficult for patients and other members of the medical community to understand what the standard of care is in ID practice. When most people are practising based on outdated evidence, cultural standards or habit, that tends to set the standard of care. However, we must keep in mind that standard of care is not equivalent to best evidence-based care. As an example, if 90% of ID docs prescribe 6 weeks of IV antibiotic for osteomyelitis at your institution, then that becomes the standard of care and the 10% of folks who are using oral agents would be the odd ones out, yet it is the minority who are providing the safer, more cost-effective care. It is important to keep an open mind and maintain some healthy skepticism when you are told “this is standard of care”.
Aggressively agree with above